Adv MS - ATI Version A

1. A nurse is preparing to administer thrombolytic therapy to a client who has an ischemic stroke. Which of the following is an appropriate nursing action? A. Start the therapy within 8 hr B. Insert an indwelling urinary catheter after therapy begins C. Monitor blood pressure every 30 min during the infusion D. Elevate the head of the bed 25 degrees and 30 degrees 2. A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? A. Place hands on the upper abdomen during inhalation B. Exhale slowly through pursed lips C. Hold breaths about 3 to 5 seconds before exhaling D. Position the mouthpiece 2.5 cm (1 in) from the mouth 3. A nurse is assessing a client who is 12 hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon? A. Heart rate 90/min B. Hgb 8.2 g/dL C. Gastric pH of 3.0 D. Absent bowel sounds 4. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? A. Regular insulin B. Furosemide C. Desmopressin D. Lithium carbonate 5. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor? A. Stool for occult blood B. Urine for white blood cells C. Fasting blood glucose D. Serum calcium 6. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) History & Physical Reports productive cough with yellow sputum for the past 2 weeks. Reports nausea, vomiting, night sweats and 3.2 kg (7lb) weight loss in the past month. Reports “always feeling tired”. Vital signs Blood pressure 128/85 Respirations 26/min unlabored with slight wheezing in right lower lobe Heart rate 85/min Temperature 38.6 (101.4 F) Oxygen saturation 94% Prescriptions Acetaminophen 650 mg PRN fever greater than 38 C (101F) Ondasteron 24 mg PRN nausea Oxygen 2L per nasal cannula PRN Sputum sample for culture Chest X-Ray Airborne precautions A. Obtain a sputum sample for culture B. Prepare the client for a chest X-Ray C. Initiate airborne precautions D. Administer ondansetron 7. A nurse is contacting the provider of a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptions should the nurse anticipate? A. Intravenous dexamethasone B. Transmucosal fentanyl C. Oral acetaminophen D. Intramuscular meperidine 8. A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction? A. QRS duration B. ST segment C. T wave D. PR interval 9. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of the following instructions should the nurse include? A. Apply over-the-counter moisturizer to the radiation site. B. Cover the radiation site loosely with a gauze wrap before dressing. C. Use a soft washcloth to clean the area around the radiation site. D. Pat the skin on the radiation site to dry it. 10. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? A. Acetaminophen B. Furosemide C. Diphenhydramine D. Pantoprazole 11. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia. Which of the following findings indicates effectiveness of the medication? A. Lungs clear B. Hyperactive bowel sounds C. Blood pressure 90/50 mm Hg D. Apical pulse 82/min